Human tragedy of the LAM Mozambique air crash

Victoria Moores looks at the facts behind the human tragedy of the LAM Mozambique Embraer 190 air crash as the final accident report is published.

Namibia has concluded that the fatal crash of a LAM Mozambique Embraer 190 on November 29 2013, which killed all 33 people on board, was most likely deliberately caused by the aircraft’s 49-year old captain.
“The inputs to the auto flight systems by the person believed to be the captain, who remained alone on the flight deck when the person believed to be the co-pilot requested to go to the lavatory, caused the aircraft to depart from cruise flight to a sustained controlled descent and subsequent collision with the terrain,” said the final accident report.
Recent pilot suicide events, including the Germanwings Airbus A320 crash in March 2015, led to recommendations that two people should remain on the flight deck at all times.
LAM Mozambique already had this policy in place and was credited by investigators as having “advanced proactive safety procedures that were way above the international minimum standards”.
However, the report said there was no conversation after the first officer left the cockpit, suggesting this procedure was not followed. This was cited as a contributing factor.
LAM flight TM470 departed Maputo in Mozambique at 09:26UTC, bound for arrival at Luanda in Angola at 13:10, with 27 passengers, two pilots, three cabin crew and an engineer on board. The E190, registered C9-EMC (MSN19000581), was a year old and had been inspected three flight hours earlier. Weather conditions were fine, with an 11kt wind, a few scattered clouds at 3,000ft, and unrestricted visibility.
The flight started normally and the crew were in radio contact with Gaborone Area Control Centre in Botswana during the cruise. “Most of the conversation in the cockpit for the first one hour and 50 minutes of the flight was dominated by general discussion about the country’s politics and social activities. There was a cordial, if not pleasant, conversation between the two crew members in the cockpit; at no point was there a hint of any unprocedural activities or other deviation,” the report said.
Around an hour and 50 minutes into the flight, the first officer left the cockpit to use the lavatory. After his exit, the door electronically locked, leaving the captain alone on the flight deck.
At the time of the flight, one Gaborone controller was handling two sectors – Area East and Area West – covering Botswana’s entire upper airspace. This is normally a job for two people. The last communication between the crew and Gaborone control was at 10:19:32.
Namibian radar data shows the aircraft started a rapid descent from flight level (FL) 380 at 11:09:07, 72nm south of the AGRAM reporting point, which marks the handover between Gaborone and Luanda air traffic control. However, the controller did not notice TM470 deviate from its flight plan in the western sector because he was focused on a false conflict alert from the eastern sector.
At 11:06:36, the captain manually changed the altitude three times from 38,000ft to 592ft – compared with the crash site’s elevation of 3,600ft above mean sea level (AMSL) – and altered the speed several times, until it neared maximum limits. Just under seven minutes after leaving the cockpit, the first officer started banging on the locked door. There were audible alerts sounding.
“Actions performed by the captain indicate explicit knowledge of the EMB-190 systems and, specifically, the automatic flight control system that is evident as the entire descent was conducted with the autopilot engaged and no force applied to the control columns,” said the report. The inputs were “commanded rather than inadvertent”, as they were logical counter-responses to the autopilot.
The E190 was lost from radar at 11:15:49. It descended at around 10,158ft/min at a speed “way higher” than 309 knots. “Speed brakes are displayed as being deployed, an indication of desire to achieve the highest rate of descent in autopilot mode.”
The aircraft hit the ground in a remote area of the Bwabwata National Park, Namibia, at 11:16:04, with the flight control surfaces and gear retracted and the engines still running. Its aircraft nose pitch was approximately -8° degrees just before impact.
“The aircraft was intact before the first impact with the terrain,” said the report. “Due to the high rate of impact with terrain and the post-impact fire, the aircraft was totally destroyed and there were no survivors.” The debris stretched for 487 metres.
The report said there was no evidence of airframe or engine failure, system malfunction, depressurisation, stall, weight and balance problems, in-flight fire or explosion. The pilot made no distress calls.
At 11:17:33, after the impact, the LAM Mozambique crew failed to acknowledge instructions from the Botswanan controller about the Luanda handover and they did not report at AGRAM as expected at around 11:19.
The Gaborone controller did not initiate an alert when this mandatory reporting point was missed and the radar did not flag the rapid descent and flight plan deviation. Despite these shortcomings, the report said: “There was no evidence to suggest that Air Traffic and Navigational Services (ATNS) procedures and actions contributed to this accident.”
Around 12:40, the Namibian police received reports from Botswanan villagers, living near the border, of a low flying aircraft, explosions and a smoke column in Bwabwata National Park.
The remote site could only be accessed by all-terrain vehicles. During the afternoon, the weather deteriorated into rain and thunderstorms, so the search and rescue team were unable to locate the wreckage until around 07:00 on November 30.
One emergency locator transmitter (ELT) was found relatively intact, but its antenna cable was cut on impact, so global emergency centres received no signal. The report identified the ELT’s failure to activate as a “particular weakness” and questioned their effectiveness, citing Australian Transport Safety Board (ATSB) research, which showed they only work in 40-60% of cases where they should be triggered.
“Antennas are located usually on a remote part of the aircraft fuselage away from the actual ELT transmitter, which then requires a long cable that raises the possibility of disconnection when there is an accident,” said the report, suggesting the need for an integral antenna, similar to those used in mobile phones.
The cockpit voice and flight data recorders, which were damaged by the heat of the fire, were found and sent to the America’s National Transportation Safety Board (NTSB) for analysis. The data was successfully retrieved and the last 12 minutes of the flight were reconstructed by Embraer test pilots on Azul’s E190 simulator in Brazil. The preliminary report was released on December 18 2013.
The 49-year old captain had accrued more than 9,000 flying hours, including 2,519 on the aircraft type. He held a valid medical certificate and had no restrictions on his license.
The 24-year old first officer was relatively new to the E190. He had 1,183 flying hours, but only 101 on the type, accumulated over the previous 90 days.
Both crew members were properly rested – the captain had the previous day off – and both were well within their duty times.
However, according to family members and friends, the captain had been through “numerous life experiences” including a separation from his first wife, who he had not divorced almost 10 years later; the suspected suicide of his son, who died in a car accident on November 21 2012 and whose funeral he did not attend; and the fact that his youngest daughter had recently undergone heart surgery.
The investigators were not able to secure information on the captain’s financial position due to “huge” bureaucratic and legal hurdles.

Safety recommendations
• The Mozambique Civil Aviation Authority should ensure that the two-person cockpit rule is adhered to at all times.
• The International Civil Aviation Organization (ICAO) should establish a working group into “threat management” from both sides of the cockpit door and stop authorised crew members from being locked out.
• The ICAO should look at visual recording, both inside and outside the cockpit, to establish who is in there, who is controlling the aircraft and where their hands are in relation to the controls.
• The ICAO should speed up its work on global flight tracking, including research and implementation of other methods beyond ELT systems.

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